Doctors reluctant to give young women permanent birth control

When Lori Witt began pursuing a tubal ligation at age 27, she said physicians refused to even discuss it with her, telling her she was too young and might change her mind about having children.

For more than a year, Witt tried to get sterilized. Finally she went with her 28-year-old husband to a military medical clinic overseas, where Witt said he was given a vasectomy with few questions asked.

Decades after sterilization became broadly available to women in the U.S., some still have trouble obtaining one of the safest and most effective forms of birth control.

The American College of Obstetricians and Gynecologists says nobody who seeks sterilization should be denied. But some women say the reality can be much different, especially for younger women and those without children.

In interviews and on Internet forums, women report facing resistance and flat-out refusal from health care providers as they seek permanent contraception. Along the way, they encounter sexist and paternalistic attitudes, such as the assumption that all women desire children or that they'll come to regret their decision.

"I've yet to come across a story of a woman without children who was granted sterilization on her first request," said Cristina Richie, a Massachusetts professor whose report on voluntary sterilization among child-free women was published by the Hastings Center, a bioethics research institute.

Julie Palm of Colorado Springs, Colo., received a tubal ligation three years ago when she was 22, but not without a fight.

"When I met with my first OB-GYN, he seemed to struggle with the idea," Palm said. "He was uncomfortable with sterilizing someone so young ... but I refused to back down. He agreed with the point that it was my body."

In addition to the fear of regret, doctors who are reluctant to sterilize a young woman may have misgivings because of their own religious beliefs, concerns about insurance coverage or potential liability, and the fact that other effective forms of long-term birth control exist.

"I strongly discourage it under age 30 because I've seen so many people change their minds," said Dr. John Merling, a family medicine specialist in Wilmington, Ohio. "They come in and are absolutely sure they want it done."

About 13 percent of women who obtain a tubal ligation express regret within 14 years, according to the U.S. Collaborative Review of Sterilization, though the CREST study found rates to be higher among younger, poorer and less-educated women.

But for many women, the potential cost of an unplanned pregnancy — an unwanted child or an abortion — or side effects from other forms of birth control are risks that far outweigh the potential for regret.

"Regret is the competent woman's burden, not the doctor's," said Richie, an adjunct professor at the Massachusetts College of Pharmacy and Health Sciences. "Very few providers of other permanent elective treatments like plastic surgery refuse treatment over fear of regret. Why should sterilization be any different?"

Physicians may fear doing something the patient might later view as detrimental, said Katie Watson, an assistant professor in the medical humanities and bioethics program at Northwestern University's Feinberg School of Medicine. "That's upsetting. No physician wants to feel like they've harmed a patient."

But Watson said the physician's focus should be ensuring that the patient receives adequate counseling beforehand. Informed consent also protects doctors from lawsuits, she said.

"Patients get to make the decisions because they are the ones who have to live with them," she said.

Doctors are significantly more likely to discourage a patient from undergoing surgical sterilization if she is younger, has fewer children and is not in full agreement with her husband, according to a national survey of women's physicians in the U.S. that was published in 2011 in the journal Human Reproduction. Nevertheless, nearly all the physicians said they would help the patient obtain the procedure if she persisted.

In a traditional tubal ligation, the fallopian tubes, which carry the eggs from the ovary to the womb, are burned, clipped, cut or tied to prevent sperm and egg from meeting. Another method, called Essure, involves implanting tiny coils that create a blockage inside the fallopian tubes.

Some doctors say they find that women often aren't aware of long-lasting but reversible alternatives to sterilization, noting that intrauterine devices (IUDs) and contraceptive implants are equally effective at preventing pregnancy and may even be safer.

"Many women see the benefits of closing the door forever so they don't have to think about it," said Dr. Nancy Stanwood, an associate professor of obstetrics and gynecology at the Yale School of Medicine. "But we could do a better job of explaining alternatives. I've certainly had patients come, ready to convince me to do tubal. But when I tell them about alternatives they say, 'Wait, that sounds so much better!'"

In addition, some women hold mistaken beliefs about the permanency of tubal ligation. In one survey of women who had undergone the operation, 35 percent thought the fallopian tubes would grow back together or unblock themselves after five years.

Tubal ligations can be reversed, but the process requires major surgery and does not always restore fertility. Reversal is also expensive and often is not covered by insurance.

Before American contraceptive practices underwent a revolution in the 1960s, tubal sterilization was mainly used to prevent pregnancy in women with severe medical problems; some women also were sterilized without their consent as part of the eugenics movement.

In the 1950s, a woman who wanted to control her fertility with a tubal ligation had to meet arbitrary standards set by hospitals, said historian Rebecca Kluchin, an associate professor of history at California State University at Sacramento.

The "120 rule," for example, held that a woman was ineligible for sterilization unless her age, multiplied by her number of children, totaled at least 120. That meant a 30-year-old woman had to have four children before she could be sterilized, said Kluchin, the author of "Fit to Be Tied: Sterilization and Reproductive Rights in America 1950-1980."

Many states also had laws that prohibited the sale or use of birth control, even by married people. But after federal courts removed the last restrictions in 1972, sterilization quickly became one of the most popular forms of contraception.

Yet some women who seek it out still are told they might want to reconsider. Comments such as, "You'll change your mind," "What if your parents thought like you?" and "What if you meet the right person and he wants to have children?" are so common that the women derisively call them "bingos."

"Some physicians might not believe women in their 20s," Watson said. "It's a radical proposition for a woman to say, 'I never want to be a mother.' It challenges a foundational paradigm."

Anne Trate, 28, of Pittsburgh, said she's certain she never wants children, in part because she's been diagnosed with bipolar disorder. If she became pregnant she'd have to stop taking her medications, she said, and that might place her life in danger.

"I'm not even sure I could care for children if I had them. I have to stay balanced," said Trate, who so far hasn't been able to find a doctor willing to help.

Overall, satisfaction rates are high among women who are successfully sterilized. Even among women who are under 30 when they undergo the procedure, 80 percent do not regret their decision, according to the CREST data.

"Sterilization isn't the first thing you do," Richie said. "You've usually been on birth control for years and thought about this for a while."

It's difficult to find comparable data about how many men regret their vasectomies, Richie said, as research more often frames the issue in terms of the regret of the man's female partner.

But "information on the Internet indicates that child-free men have almost no trouble finding a doctor to perform a vasectomy," she wrote in the Hastings Center Report. "This fits with the view that men are less bound by cultural norms of parenthood and more competent to make decisions."

Watson said regret is a fair topic of discussion for any procedure because doctors need to know what the patient is thinking. "Does she want a tubal ligation because she's in an abusive relationship? You want a doctor who wants to do what's best for you. The question is what happens when you and your doctor disagree," Watson said.

In Witt's case, the one physician who would consider sterilizing her first required Witt to try an IUD for six months, she said. Witt refused, citing a problematic history with artificial hormones and other health conditions.

"The risks and side effects of an IUD were not acceptable to me," said Witt, who lives near Omaha, Neb. "But the risks and side effects of a tubal were not acceptable to him."

In the end, she was left feeling condescended to and angry. "I felt like I was only allowed to make reproductive decisions if they fell in line with the status quo," she said. "Basically my life could be anything I wanted it to be as long as it was motherhood."